Indiana University Northwest Grant Form Page 2
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Worksheet
Calendar Year 2015
**MUST BE COMPLETED FOR ITEMS 2, 3, 4
Important: Be sure not to leave anything blank. If there is no income please place a zero.
Income for January 1, 2015 to December 31, 2015
For Office Use
Jan 1, 2015-
Today-
Changes to be
Today
Dec 31, 2015
made in P/S
Estimated
Actual
1.
Student’s gross earnings.
(wages, salaries, net business or farm income)
Do not include Federal Work-Study wages
2.
Spouse’s gross earnings.
(wages, salaries, net business or farm income)
Do not include Federal Work-Study wages
3.
Father’s gross earnings.
(wages, salaries, net business or farm income)
Do not include Federal Work-Study wages
4.
Mother’s gross earnings.
(wages, salaries, net business or farm income)
Do not include Federal Work-Study wages
5.
Other taxable income.
(unemployment compensation)
6.
Welfare benefits
(TANF).
Including Temporary Assistance for Needy Families
2
Do not include Food Stamps.
7.
Social Security benefits that were not taxed.
(such as SSI)
8.
Child support you are receiving for all children.
Do not include foster care or adoption payments.
9.
Veteran’s non-education benefits, such as Disability, Death
Pension, or Dependency & Indemnity compensation (DIC)
and /or VA Education Work-Study allowances.
10. Any other untaxed income and benefits, such as worker’s
compensation, untaxed portions of railroad retirement
benefits, Black Lung Benefits, disability, etc.
TOTAL
Actual
Estimated
The Please fill out, sign, and return all required documentation to the Office of Financial Aid and Scholarships.
By signing, I agree to all of the statements listed below:
•
I give the Office of Financial Aid and Scholarships permission to verify any information that I provide on this form.
•
I certify that all the information provided on this form is correct.
•
I understand that if I purposely give false or misleading information on this form, I am liable for cancellation or
repayment of all or part of my financial aid.
•
I understand that submitting this form does not automatically increase my financial aid awards.
_______________________________________________________
____________
Student Signature
Date
_________________________________________________________
____________
Parent Signature (if applicable)
Date
Please return the completed form to:
Revised 03/05/15
Office of Financial Aid and Scholarships • 3400 Broadway, Rm 111 •
Gary, IN 46408-1197
Phone: (219) 980-6778
• Fax: (219)981-5622
• Email: finaidnw@iun.edu
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